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General NPI Number Information
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NPI Number | 1487863254
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Entity Type | Organization
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Legal Business Name | KHAZEN ATHLETIKARE, LLC
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Dates
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Enumeration Date | 05/21/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 11892 WEXFORD PLACE DR
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City | MARYLAND HEIGHTS
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State | MO
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Zip | 63043-1763
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Country | US
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Telephone | 314-368-9772
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Fax |
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Provider Business Mailing Address
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Address Line | 11892 WEXFORD PLACE DR
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City | MARYLAND HEIGHTS
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State | MO
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Zip | 63043-1763
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Country | US
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Telephone | 314-368-9772
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | LORI ALLISON KHAZEN
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Credential | MS ATC, CSCS
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Telephone | 314-368-9772
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 2000157569
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License Number State | MO
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